Application of whole-mount section of lung specimen in study of radiologic-pathologic correlations

We evaluated the usefulness of the whole-mount section of the inflated-fixed lung specimen in the study of radiologic-pathologic correlations. Altogether, 24 resected fresh lobe specimens with 1.5- to 3.0-cm solitary pulmonary carcinomas or tuberculomas were inflated with air, intrabronchially fixed by infusing Heitzman's solution, and finally cut into 10- to 15-micron-thick whole-mount sections for the histopathological examination. All 24 inflated-fixed lobes were satisfactorily soft as sponge, sufficiently springy, and kept their original shape. All whole-mount sections clearly presented the complete morphological features of the whole lobes, and could be directly observed by the naked eye and examined under microscopy. The use of the whole-mount section of the lung specimen may facilitate precisely and effectively the studies of the radiologic-pathologic correlations.

[A case of disseminated bone tuberculosis in an aged patient]

It is described the case of a 75-year-old woman admitted to the hospital for physical degeneration, serious decline in mental status and swelling in the pre-sternal region. The diagnosis of a severe, destructive and infrequent form of disseminated bone tuberculosis was made. This case underscores the risk of tuberculosis to which the elderly, in particular, are subject. Moreover, the lack of specificity of symptoms and laboratory findings and the presence of concomitant chronic pathologies can mask the clinical picture, rendering the hypothesis of tuberculosis highly improbable. Computed tomography studies of this patient also disclosed the seldom encountered finding of severe bone destruction, particularly of the vertebrae and sternum, caused by infiltration of caseating granulomas.

Value of CT scan in the diagnosis of meningitis

OBJECTIVE

To study the diagnostic test characteristics of computed tomography (CT scan) in differentiating tuberculous (TBM) and pyogenic (PM) meningitis.

DESIGN

Prospective diagnostic test evaluation.

SETTING

Teaching hospital.

METHODS

Children beyond 1 month of age admitted with meningitis were enrolled prospectively and CT scan done. Results of CT scan were compared with predefined gold standards for the diagnosis of either TBM or PM.

RESULTS

CT scan was performed in 154 patients with meningitis. Of these 94 were TBM, 52 had PM and 8 were indeterminate and excluded from analysis. Basal enhancement, ventriculomegaly, tuberculoma and infarction were all significantly more common in the TBM group, while subdural collections were seen more in the PM group. The highest sensitivity (89.2%) and specificity (100%) for diagnosis of TBM were found for basal enhancement or tuberculoma or both.

CONCLUSIONS

CT scan can be used to effectively distinguish TBM and PM.

Vascular manifestations of small solitary pulmonary masses. Angiographic-pathologic correlations and clinical significance

RATIONALE AND OBJECTIVES

By performing pulmonary specimen angiographies, the authors attempted to determine the pathologic correlations of the vascular-related radiologic manifestations within, at the edge of, and adjacent to the small solitary pulmonary masses, and to evaluate their usefulness in differentiating small bronchogenic carcinomas from tuberculomas.

METHODS

A total of 29 resected lobe specimens with 1.5- to 3.5-cm solitary pulmonary masses, including 24 carcinomas and 5 tuberculomas, were studied prospectively with preoperative radiographs, postoperative specimen arteriographies (in 19 carcinomas and 5 tuberculomas), and venographies (in 5 carcinomas), 10- to 15 micrograms-thick whole-mount sections, and 5-micrograms-thick slices for the examination of angiographic-pathologic correlation. Another series of chest radiographs and conventional tomographs of 100 patients with 1- to 3-cm peripheral pulmonary masses, including 60 carcinomas and 40 tuberculomas, were reviewed retrospectively and analyzed with the chi-square test.

RESULTS

Specimen angiographies showed the intralesion avascularity, small arterial speculation, and lobulation or notch at the mass margin with arterial compression, as well as vascular convergence to the mass, in both carcinoma and tuberculoma groups. The irregular arterial wall (79.2%) and venous dilation distal to the mass (100%) were found in the carcinoma group only. Microscopically, arterial or venous fibrous hyperplasia was observed in both carcinomas and tuberculomas, whereas the arterial erosion by tumor tissue and tumor emboli within the vessels were found in carcinomas only. The retrospective review of the 100 patients showed that two radiologic signs of the vascular convergence to the mass and the vascular dilation distal to the mass occurred at similar frequencies (12%-13%) between the carcinoma and tuberculoma groups.

CONCLUSIONS

In addition to compression of vessels by tumor and vessel occlusion by tumor embolus, pulmonary vascular fibrotic hyperplasia can cause intramass avascularity. Small vessels running vertically into or from the mass margin can construct the spiculation sign of the tuberculomas. Any evidence of pulmonary vascular irregularity will indicate a bronchogenic carcinoma. The vascular convergence to the mass and the vascular dilation distal to the mass are not specific radiologic signs for small solitary bronchogenic carcinomas.

Pulmonary parenchymal manifestations surrounding small peripheral masses: pathologic correlation with chest radiographs and diagnostic value

RATIONALE AND OBJECTIVES

We evaluated pathologic correlations of pulmonary parenchymal manifestations surrounding small peripheral masses and their usefulness in differentiating small peripheral bronchogenic carcinomas from tuberculomas.

METHODS

We evaluated 29 resected lobe specimens with 1.5- to 3.5-cm solitary pulmonary masses, including 24 carcinomas and five tuberculomas. These specimens were prospectively studied with preoperative chest radiographs, postoperative specimen radiographs, 10- to 15-microns-thick wholemount sections, and 5-microns-thick slices. A total of 100 chest X-rays and conventional tomography scans of 1- to 3-cm peripheral pulmonary masses, including 60 carcinomas and 40 tuberculomas, were retrospectively reviewed and analyzed.

RESULTS

The pulmonary parenchymal manifestations surrounding the masses presented as small infiltrates and nodular protrusions, thickened strands, and "double track" shadows, which extended from the proximal margin of five tuberculomas (100%, 5 of 5) and from the distal margin of 17 carcinomas (71%, 17 of 24). These pulmonary changes represented caseous material spreading from tuberculomas into the proximal bronchus and alveolar inflammatory exudation distal to the carcinomas. The proximal pulmonary manifestations were significantly more frequent in tuberculomas than in carcinomas (p < .01), whereas the distal pulmonary manifestations were more often found in carcinomas than in tuberculomas (p < .01).

CONCLUSION

The radiologic findings of the pulmonary parenchymal manifestations proximal or distal to the masses may be valuable radiologic signs for distinguishing between tuberculomas and small peripheral bronchogenic carcinomas, even though there is still considerable crossover between the two disease populations in the findings.

Computer-aided differential diagnosis of small solitary pulmonary nodules

A new digital processing method was developed to improve the specific diagnosis of small (up to 3 cm) solitary pulmonary nodules on lung tomograms. The proposed method gives advanced imaging of diagnostically important details and structures of the nodule. It helps the physician easily identify known diagnostic features and discover some additional ones that are useful for reliable verification of cancer, tuberculoma, and hamartoma. X-Ray morphological comparison confirmed that all details, displayed on the processed tomogram, corresponded to morphological structures on postsurgical histotopograms. The method can give additional information to data from conventional and computed tomography, especially in the case of small radiographically indeterminate pulmonary opacities.

Tuberculosis of the nasal fossa manifested by a polypoid mass

Since the introduction of effective antituberculous chemotherapy, upper respiratory tract tuberculosis is infrequent; nasal involvement is a very rare form of this disease. In this localization, tuberculosis is usually unilateral and typically discloses a definite granular mass or an ulcer. We report a case manifested by an intranasal mass on computerized tomography scans that evolved as chronic rhinitis.

Radiologic manifestations of pulmonary tuberculosis

In summary, the following points are reemphasized: 1. The chest film is the mainstay in the radiologic evaluation of suspected or proven pulmonary TB. CT is occasionally useful for clarifying confusing findings but has not been conclusively shown to have a significant impact on patient management. 2. Primary TB is increasingly a disease of adults. 3. Primary TB usually manifests as a parenchymal consolidation in any pulmonary lobe or segment. Distinguishing features from typical bacterial pneumonia include associated adenopathy, lack of systemic toxicity, failure to respond to conventional antibacterial therapy, and recent PPD conversion. 4. Associated ipsilateral hilar and/or mediastinal adenopathy is almost universal in children with primary TB but is less common in adults. Adenopathy without parenchymal disease is an unusual but well-reported manifestation. 5. Many of the so-called unusual manifestations of adult TB are the usual manifestations of primary disease. The terms adult and childhood TB should be discarded. 6. Postprimary TB typically manifests as a heterogeneous, often cavitary opacity in the apical and posterior segments of the upper lobes and the superior segments of the lower lobes. Lymphadenopathy is rare. 7. Activity of postprimary disease cannot be accurately assessed by chest radiography. Radiographic stability for 6 months and negative sputum cultures is the best indicator of inactive disease. The descriptive terms inactive or old TB should be discarded in favor of radiographically stable TB, as viable bacilli may persist despite adequate therapy. 8. Cavitation is the most important radiologic finding in postprimary disease. Cavitation implies a high bacillary burden, high infectivity, and is associated with numerous complications including endobronchial spread, tuberculous empyema, hematogenous dissemination, pulmonary artery pseudoaneurysm, and so forth. 9. Tuberculous pleurisy is more common in primary than postprimary disease. It is a common presenting manifestation in young adults. The effusions are unilateral, large, and self-limited. The pleural fluid usually is a serous exudate with a marked lymphocytosis. Fluid cultures are frequently negative. Correct diagnosis and therapy is important, as untreated patients are at high risk for subsequent pulmonary reactivation. 10. Miliary disease is also more common in primary than postprimary disease; however, its frequency in elderly patients with postprimary TB is increasing. This form, known as late generalized TB, is apt to be misdiagnosed or not diagnosed in life and has a high mortality.

CT scans of cranial tuberculosis

Tuberculosis of the central nervous system is still an important cause of death or significant neurologic disability. Prompt diagnosis and early treatment are extremely important to reduce its morbidity and mortality. The main forms of intracranial tuberculosis are represented by tuberculous meningitis, meningeal or parenchymal tuberculomas, and tuberculous abscess formation. Sequelae consist of hydrocephalus, calcifications, and areas of encephalomalacia. Less frequent manifestations include tuberculous osteitis of the skull and tuberculous otomastoiditis. Although MR imaging is in general somewhat more sensitive to the detection of cranial tuberculosis, CT is the diagnostic imaging mainstay in many clinical settings to demonstrate the various aspects of cranial tuberculosis on initial presentation and to monitor the evolution of the disease and response to therapy.

Pancreatic tuberculosis

Pancreatic tuberculosis is a rare clinical entity. It most often is associated with miliary tuberculosis or occurs in the immunocompromised patient and is extremely uncommon in nonendemic geographic regions. Described is a case of isolated infection of the pancreas by Mycobacterium tuberculosis occurring in an otherwise healthy individual from North America who presented with recurrent hyperamylasemia and fevers. Computerized tomography revealed a multiloculated lesion in the head of the pancreas. Intraoperative biopsies demonstrated granulomas. The diagnosis was confirmed by positive cultures. Triple drug therapy was effective in alleviating symptoms, and a follow up CT revealed a normal pancreas. One year following operation the patient remains well.

[Imaging of hepatic tuberculoma]

We describe a case of localized macronodular tuberculosis of the liver, the so-called hepatic tuberculoma. Liver US scan demonstrated an hypoechoic well-delineated lesion of the left liver lobe. Liver CT scan demonstrated a hypodense lesion before and after contrast enhancement. Liver MR scan demonstrated a lesion hypointense to liver on T1-weighted images and isointense to liver on T2-weighted images.

Epidural spinal tuberculoma

Epidural tuberculoma in the spine is a rare lesion and its pre-operative distinction from tumour is usually not possible. One such case who presented with radiological appearance suggestive of spinal tumour is described.

Abdominal tuberculoma mimicking a pancreatic neoplasm: report of a case

We report herein a case of clinically solitary abdominal tuberculoma. A 28-year-old woman was admitted to hospital for treatment of an abdominal tumor shown to be located in the head of the pancreas and compressing the superior mesenteric vein by echosonography and computed tomography (CT). There were no clinical signs or symptoms of tuberculosis in the lungs or abdomen. Thus, under the diagnosis of a neoplasm of the pancreas, an exploratory laparotomy was performed which revealed tuberculosis. The patient made an excellent recovery on anti-tuberculous treatment, and no evidence of a tumor was seen on a CT scan performed 6 months after the initiation of treatment. Abdominal tuberculoma is often mistaken for a malignant neoplasm and the nonsurgical diagnosis of this entity continues to be a challenge.

Solitary muscular involvement by tuberculosis: CT, MRI, and scintigraphic features

The authors reported computed tomography (CT), magnetic resonance imaging (MRI) and scintigraphic findings of a patient with solitary muscular tuberculosis in the forearm. All these findings resembled those of other granulomatous inflammatory lesions in the soft tissue such as muscular sarcoidosis.

[Cardiac tuberculoma; value of echocardiography and therapeutic management apropos of a case]

The authors report the case of a patient with a large mass in the right ventricle which was a tuberculoma without pulmonary disease. The severity of the right ventricular obstruction required surgical intervention with quadri-antitubercular therapy. Myocardial tuberculomas are very rare and usually reported as post-mortem findings. Only four cases resulting in cure have been previously reported. Current means of investigation such as echocardiography and endomyocardial biopsy allow rapid diagnosis of these tumours and should lead to better medical management with possible surgical intervention and a higher therapeutic success rate.

Solitary pulmonary nodule: preliminary study of evaluation with incremental dynamic CT

PURPOSE

To use incremental dynamic computed tomography (CT) to evaluate solitary pulmonary nodules (SPNs).

MATERIALS AND METHODS

Thirty-two adult patients with SPNs less than 3 cm in diameter had 18 primary lung cancers, 10 tuberculomas, and four hamartomas. The CT numbers of the inner area of the nodule were calculated before and 30 seconds, 2 minutes, and 5 minutes after administration of contrast material.

RESULTS

All lung cancers and one of four hamartomas showed significantly greater enhancement (P < .0001) than benign SPNs, which did not show enhancement (except for one hamartoma). All lung cancers and one of four hamartomas showed complete enhancement, one hamartoma showed peripheral enhancement, two hamartomas and eight of 10 tuberculomas showed capsular enhancement, and two tuberculomas showed no enhancement.

CONCLUSION

Maximum attenuation of 20-60 HU appears to be a good predictor of malignancy.

Intraorbital extraocular tuberculosis: a report of three cases

Intraorbital extraocular tuberculosis is a rare disease. We have recently treated three cases with a good outcome. This article discusses the clinical radiologic and operative features that we encountered. Tuberculosis disease should be considered as one of the differential diagnosis of intraorbital extraocular space-occupying lesions in India.

[Clinical, radiologic and morphologic characteristics of localized forms of pulmonary tuberculosis. Tuberculosis and hypoplasia]

Clinical and x-ray examinations and study of operation material from 555 patients with local forms of tuberculosis permitted the authors to distinguish three form of the condition: tuberculoma (77% of cases), cavitary (cavernous) tuberculosis (16%), and tuberculosis of the bronchi (5%). Morphologic investigations showed the local tuberculosis develops at small sites of pulmonary tissue hypoplasia. Sites of hypoplasia are usually concentrated in the pulmonary segments which are formed in the postnatal period, thus explaining the typical localization of a postprimary tuberculous focus. Tissue decomposition with development of destruction cavities is not characteristic of local tuberculosis. Cavitary (cavernous) form is a morphologic reflection of a tuberculous inflammation in the zone of cestous hypoplasia. Morphonesis of local forms of tuberculosis reflects its social dependence.

[Three-dimensional CT imaging of pulmonary nodules using helical scan CT]

To evaluate the usefulness of three-dimensional (3D) imaging of pulmonary nodules from helical scan CT images, 3D reconstructions were performed in 23 patients, using a CEMAX VIPstation. These cases included 15 lung cancers, six metastatic lung cancers, an aspergilloma and a tuberculoma. The equipment used was a Toshiba CT system, the X force. Helical scan CT data were acquired using up to 20 continuous 1.5 sec rotations with an X-ray beam width of 5 mm and a couchtop movement speed of 5 mm/1.5 sec, and during a single breath-hold. Axial images were reconstructed at a section interval of 2 mm. Helical scan CT permits axial images to be reconstructed at any desired position within the scanned area, and provides images without interslice gaps caused by respiratory movement. Therefore, high-quality 3D images can be obtained from these data. Concerning the optimum threshold range of CT number of 3D reconstruction, we clarified the lower and upper limits (lower/upper), as follows: 1) Solid pulmonary nodule: (-700-(-)400/-100 HU) 2) Tumor invaded to pleura or chest wall: (-700-(-)400/-200 HU) 3) Pulmonary nodule with cavity: (-700-(-)400/50 HU) 4) Small pulmonary nodule (< 10 mm): (-750-(-)600/-100 HU) In all cases, it was possible not only to demonstrate abnormal findings three-dimensionally, but also to grasp anatomical relationships among the pulmonary nodule, bronchi, vessels and chest wall. In conclusion, it was considered that 3D CT imaging provided additional anatomical information and was very useful.

Colour Doppler sonography: a new investigative modality for intraocular space-occupying lesions

We report our experience with colour Doppler sonography (CDS) in 20 normal subjects and 25 patients with intraocular space-occupying lesions. The technique provided an in vivo cross-section of the vascular topography of space-occupying lesions in real time. Colour coding and spectral analysis helped to determine the direction and pattern of blood flow. CDS was found to be a useful diagnostic adjuvant, a guide to the treatment protocol, and helped in monitoring the progress of the disease. In conditions of the eye where unclear media hindered a clinical evaluation, CDS sonography was a safe, easily reproducible and non-invasive investigative tool. With further technical advances in waveform analysis and quantitative assessment, CDS holds promise as an investigative modality of choice in the future.

Intracranial tuberculoma: clinical and computerized tomographic findings

Seven cases of intracranial tuberculoma diagnosed in northern Turkey over a 2-year period are presented, with emphasis on the CT and clinical findings. CT alone cannot differentiate tuberculoma from an abscess or other granulomatous processes, but it is still one of the most sensitive techniques for detecting tuberculomas. It provides information on the nature of the lesion and the number of loci.

[Ultrasonography in differential diagnosis of peripheral pulmonary diseases]

In 87 patients with peripheral pulmonary diseases either adhesive or close to the pleura, who were examined, ultrasonographically 64 had lung cancer and 23 benign lesions were confirmed histopathologically. Five sonographic features including configuration, echogenicity patterns, bronchial air phase in foci, margin, and pleural involvement were significantly different between malignant and benign diseases (P < 0.01). The differential ultrasonography used in this series showed a sensitivity of 61% (14/23), a specificity of 95% (61/64), and an accuracy of 86% (75/87). The results demonstrate that ultrasound is helpful in differentiating the malignant lesion from the benign one in the peripheral lung near the pleura.

[Availability of diagnosis by percutaneous needle aspiration cytology of the lung in cases who showed a peripheral solitary tumorous shadow on chest Xp and diagnostic rate of transbronchial approach]

We report the availability of diagnosis by percutaneous needle aspiration cytology of the lung (NAC) in 526 cases who showed a peripheral solitary tumorous shadow on chest Xp. The positive rate of the transbronchial approach was 62% (147 of 238) in lung cancer cases and 43% (6 of 14) in metastatic lung tumor cases. The positive rate of NAC in relation to lung cancer increased with decrease of diameter of the tumor. The positive rate of NAC was significantly higher than the positive rate of the transbronchial approach with NAC. Complications of NAC were bloody sputum (11%), pneumothorax (8%) and subcutaneous emphysema (0.2%), which did not create therapeutic problems. Pleural dissemination (0.4%) was a serious complication of NAC.

[Clinical analysis of CT image in 112 adult patients with tuberculous meningitis]

Analysis of CT image in 112 patients with tuberculous meningitis, abnormal findings were shown in 80.4% cases. They were tuberculoma, hydrocephalus, basal cistern exudation, cerebral embolism, brain atrophy, miliary nodules, tuberculous abscesses and etc. Tuberculoma, hydrocephalus and basal cistern exudation are common changes in patients of cerebromeningitis type. Basal cistern exudation is the main image in early stage patients. Hydrocephalus occurred in patients of chronic stage. Manifold lesions occurred in late stage patients. The longer the disease course, the more is the abnormal finding rate by CT image. The prognosis of patients with normal CT image is good, the patients with manifold lesions are worse than those patients with single lesion by CT image, and sequelae developed more frequently in those patients with manifold lesions.

Thoracoscopic wedge resection of peripheral lung lesions

The increasing experience with minimally invasive surgery and advances in endoscopic equipment have expanded the role of thoracoscopy to include thoracoscopic pulmonary resections. In 11 patients we have evaluated the technical feasibility of thoracoscopic wedge resection of single peripheral lung lesions. In 8 patients the lesion could be exactly identified by thoracoscopy and be effectively resected using an automatic endoscopic stapler. All lesions were located within the outer third of the lung parenchyma with a maximum distance of 1.4 cm between lesion and visceral pleura. Mean diameter of the nodules was 1.9 cm and ranged from 1.0 to 4.1 cm. Histological analysis revealed completely excised tuberculomas in 4, carcinomas in 2, hamartoma in 1, and localised fibrosis in one patient. In 3 patients the thoracoscopic approach was unsuccessful because of difficulty in identifying the lesion or impossibility of achieving a reliable assessment of the intraparenchymal extension of the tumor. In conclusion, thoracoscopic wedge resection is helpful for the diagnostic and therapeutic management of peripheral lung lesions in carefully selected patients. Continued experience is necessary to be able to establish reliable criteria to assess which types of lung lesion can be excised safely and effectively by videothoracoscopy.

Differentiating solitary small cysticercus granulomas and tuberculomas in patients with epilepsy. Clinical and computerized tomographic criteria

It is commonly believed that differentiating solitary small cysticercus granulomas and small tuberculomas in patients with seizures is difficult without resorting to an excision biopsy. The aim of this study was to formulate clinical and computerized tomography (CT) criteria to distinguish these two entities in patients with epilepsy. Toward this end, clinical and CT data from six consecutive patients with histologically proven small solitary tuberculomas and 25 consecutive patients with histologically proven solitary cysticercus granulomas were compared. Evidence of raised intracranial tension and a progressive focal neurological deficit was seen only in patients with tuberculomas (two of six cases). All tuberculomas were greater than 20 mm in size and five of the six were irregular in outline. Only tuberculomas were associated with a midline shift on CT (four of six cases). All cysticercus granulomas were less than 20 mm in size and 24 (96%) of the 25 were regular in outline, conforming to one of two characteristic patterns. No cysticercus granuloma was associated with a midline shift. Based on the above clinical findings (evidence of raised intracranial tension and a progressive neurological deficit) and CT criteria (size, shape, and association with a midline shift), it is possible to separate these two entities in a majority of patients with seizures and with a single small lesion on CT.

CT "halo sign" in pulmonary tuberculoma

The CT halo sign has been described as the CT finding of a low-attenuation zone surrounding a pulmonary nodule. It is an early clue to the diagnosis of invasive pulmonary aspergillosis. We describe a case of CT halo sign associated with a pulmonary tuberculoma. Therefore, we think that a diagnosis other than invasive pulmonary aspergillosis should be considered in the presence of the CT halo sign in immunocompetent patients.

Pulmonary tuberculoma and indications for surgery: radiographic and clinicopathological analysis

Tuberculomas of the lung are one of the more common lesions presenting a solitary pulmonary nodule, roentgenographically. We treated 36 patients with such nodules and describe here the radiologic-pathologic correlations and surgical treatment. In 21 patients, lung cancer was suspected preoperatively, based on radiographic findings of an ill-defined margin, pleural indentation and spicular radiation. Histologically, the tuberculous granuloma proliferated in the alveolar septa of the surrounding normal lung, often seen as a spicular radiation resembling lung cancer. In eight patients, tuberculoma was suspected because of radiographic findings of calcification and satellite nodules, and anti-tuberculous chemotherapy was prescribed for a few months. As this treatment was ineffective, surgical resection had to be done. Postoperative complications were nil and all of these patients are doing well at the time of preparation of this report. Anti-tuberculous chemotherapy was prescribed for 28 of 36 patients, postoperatively. We believe that surgical intervention is required for selected patients.

[CT findings of six cases with intracranial tuberculosis in National Higashi-Saitama Hospital]

We have experienced 6 cases of intracranial tuberculosis since 1985. 2 cases were diagnosed as intracranial tuberculoma without tuberculous meningitis, and 4 cases were diagnosed as tuberculous meningitis. Brain CT showed intracranial tuberculomas in three of them, and showed cerebral infarcts in two cases, and showed hydrocephalus in two cases. Brain CT on intracranial tuberculosis showed various findings. In two cases with tuberculous meningitis, brain CT showed many tuberculomas with ringed or nodular enhancement appeared after adequate chemotherapy had been started. About 1 year later, a few tuberculomas were found with homogeneous enhancement and were enlarged while the chemotherapy was continued. But later they were reduced in size. The above facts may suggest that intracranial tuberculoma could appear and be enlarged on cranial CT in spite of adequate anti-tuberculous chemotherapy during a course of tuberculous meningitis. They also suggest that the continuation of adequate chemotherapy might be necessary to the treatment of intracranial tuberculomas.

[X-ray findings in pulmonary tuberculosis in children and its complications]

Pulmonary tuberculosis is still a common disease in children, especially those of immigrant families. Prevention and diagnosis rest on the plain chest film which should remain the first step of the work-up. Apart from cerebromeningeal complication, CT scan is also useful for evaluating chest lesions including mediastinal lymphadenopathies and lung parenchyma involvement. CT scan combined with endoscopy ensures detection of complications including bronchogenic dissemination. With a few cases as illustrations, the role of roentgenographic investigations in the management of pediatric tuberculosis is outlined.

Radioimmunoscintigraphic approach for the in vivo detection of tuberculomas--a preliminary study in a rabbit model

Radioimmunoscintigraphic approach could provide a viable non-invasive alternative for the diagnosis of deeply situated tuberculomas. We have evaluated this in a rabbit model constructed to give a characteristic localized tubercular lesion, with complimentary morphological, histological and antigenic profiles. 131I-anti Myobacterium bovis (BCG) antibody was shown to localize at the lesion, where as 131I-bovine serum albumin and 99mTc-red blood cell scans were negative. The clearance of intradermally-injected tuberculous antigen could be traced into ascending lymph nodes using 131I-anti M. bovis (BCG) antibody.

[Involvement of the central nervous system in disseminated tuberculosis]

Four weeks after starting tuberculostatic treatment (with isoniazid, rifampicin, streptomycin and pyrazinamide) a 21-year-old man with pulmonary tuberculosis developed symptoms of a radiculomyelopathy as well as mild renal failure. After isoniazid and streptomycin had been discontinued and ethambutol and high doses of vitamin B6 had been added all signs and symptoms improved. However, 4 weeks later tuberculous meningitis occurred which at first seemed to respond to administration of 5 antituberculosis drugs and dexamethasone. But 3 weeks later the patient sustained a partial hemiparesis. Its cause was proven to be a tuberculoma in the region of the brainstem. During further administration of tuberculostatic drugs and glucocorticoids the symptoms gradually receded over 8 months. A 54-year-old man with pulmonary tuberculosis developed cranial nerve pareses and symptoms of cerebellar involvement (trunk ataxia, intention tremor, dysdiadochokinesia) 3 weeks after starting tuberculostatic treatment. Computed tomography revealed multiple intracerebral tuberculomas which gradually shrank with continuation of the tuberculostatic treatment plus glucocorticoids. These two case reports illustrate that in tuberculosis involvement of the CNS can express itself clinically through complex symptoms, sometimes even after the start of tuberculostatic treatment.

[Chronic granulomatous prostatitis: echographic features in patients submitted to immunoprophylaxis/therapy with BCG]

48 consecutive male patients with T.C.C. Ta-T1 and C.I.S. underwent local therapy with BCG. 4 patients presented with perineal pain and dysuria. T.R.U.S. showed hypoechoic areas with capsular infiltration. Transperineal echo-guided biopsy was taken and histology showed specific chronic granulomatous prostatitis.

Brain biopsy in tuberculoma: the risks and benefits

In developing countries, 5 to 8% of the space-occupying lesions of the central nervous system are tuberculomas. Diagnosis can be difficult in the absence of extracranial tuberculosis; computed tomography is suggestive only. To assess the value of brain biopsies in tuberculomas, the records of 15 patients aged 6 to 80 years were reviewed. Histological confirmation was obtained in 15 patients, and acid-fast bacilli were cultured from 12 patients. Intracranial hypertension was the principal sign in 11 patients; other neurological signs were related to the location of the tuberculoma. One patient had evidence of extracranial tuberculosis. Biopsy-related complications consisted of an epidural hematoma in 1 patient and hydrocephalus in another; both required additional surgery. One case of tuberculous meningitis was probably related to surgery and poor drug compliance. There was no postoperative mortality. Thirteen patients (2 were lost to follow-up) were cured after an average of 16 months of antituberculous therapy. It was concluded that the brain biopsy is useful in diagnosing tuberculoma but that there is some associated risk.

Ultrasound detection of tuberculomas of the spleen

A case of multiple tuberculomas of the spleen, detected as hypoechoic masses on ultrasound and subsequently proved at operation and histopathology, is presented. This was the only manifestation of the disease.

Synthesis of 2-[123I and 124I]-iodoisonicotinic acid hydrazide--potential radiotracers for tuberculosis

The radiochemical syntheses of methyl 2-[123I]-iodoisonicotinate, 2-[123I]-iodoisonicotinic acid hydrazide and 2-[124I]-iodoisonicotinic acid hydrazide was accomplished. Iodine-123 was incorporated in the methyl ester molecule by an exchange reaction in glacial acetic acid. The average efficiency of iodine exchange reaction was (92.6 +/- 4.5)%. This radiotracer was extracted with ether and the solvent was evaporated. The residue was re-dissolved in anhydrous ethanol and treated with hydrazine under anhydrous conditions to obtain 2-[123I]-iodoisonicotinic acid hydrazide. The overall radiochemical yield was 69%. Biodistribution data of both radio-tracers in male Sprague-Dawley rats were collected. This is the first report of SPECT radiopharmaceuticals which may be useful for differential diagnosis of intracranial masses (tuberculoma vs glioma), and CNS tuberculosis in immunosuppressed subjects.

Intracranial tuberculosis in children: CT appearance and clinical outcome

We retrospectively evaluated the CT studies of 9 children who presented with intracranial tuberculosis during 1981-1987, and compared their radiographic appearance with the clinical outcome. The most common radiographic findings were: 1) ventriculomegaly (7/9) ,2) tuberculoma formation (6/9), and 3) infarction (4/9). Of 7 patients with ventriculomegaly, 3 required a ventricular shunt and 2 had spontaneous resolution of ventricular dilatation. Four children with ventriculomegaly were moderately or severely retarded, one had cognitive dysfunction, and one was neurologically normal. Four of six children with tuberculoma also had infarction and/or ventriculomegaly; of these four children, three were moderately or severely retarded. Two patients with tuberculoma as the only intracranial abnormality had complete resolution of the granuloma with normal neurologic outcome following antituberculous therapy. The four children with large vessel infarction also had ventriculomegaly; three had poor clinical outcome. The presence of tuberculoma alone is not necessarily predictive of poor neurologic outcome; age less than 20 months, infarct, and/or ventriculomegaly are usually associated with sequelae.

[A case of symmetrical and bilateral tuberculoma of both lung apices]

A 28-year-old man with solitary nodular shadows in both lungs was admitted. The erythrocyte sedimentation rate was accelerated, with elevation of the serum IAP values, and the tuberculin reaction was strongly positive. The X-Ray film of the chest revealed symmetrical and bilateral nodular shadow in both lung apices. Both nodular lesions revealed a tendency to grow, pleural indentation and spiculated margins. Moreover, the tomogram film showed convergence of the pulmonary vein branch in the central part of the left apex nodule. Since it was extremely difficult to distinguish these lesions from malignant nodules based on just radiographic findings, an exploratory thoracotomy was carried out. The histologic diagnosis of both nodules was tuberculoma. Currently, the radiologic criteria used to distinguish between benign and malignant lesions are assessment of size, contour, absence or presence of tumor growing tendency by serial radiographs, calcification as well as the relation between the lesion with the pulmonary vasculature. It was concluded that, as was shown by this case, the radiographic criteria appear to be insufficient to categorize the nature of a lesion into benign or malignant. Consequently, more reliable non-invasive techniques would be desirable for the accurate diagnosis of tuberculosis.

[Computed tomographic findings of intracranial gliosis: report of 2 cases]

Two cases of intracranial gliosis documented by surgery and histopathology are presented. Intracranial gliosis is a nonspecific reaction to different neoplastic and non-neoplastic lesions. The CT findings were also non-specific and the disease could not be differentiated from other neoplastic and non-neoplastic lesions. The clinician and radiologist should be aware that in patients with intracranial gliosis of unknown etiology, clinical and CT follow-up studies should be done diligently in order to uncover the underlying pathology.

Computed tomography-guided and stereotactic techniques in the diagnosis and treatment of cerebral tuberculoma

The advantages of computed tomography-guided preoperative localization of brain lesions are illustrated in four cases of solitary tuberculoma and in one case of tuberculous abscess of both the cerebrum and the cerebellum. The role of stereotactic diagnostic techniques is emphasized. The clinical presentation and the computed tomography findings in these patients were equivalent to those from glial or metastatic tumors. Synchronous pulmonary tuberculosis was not present in these patients, but in three patients there was metachronous tuberculosis. Tuberculous meningitis had not developed in any of the patients.

[Intracerebral tuberculomas. A CT study of 14 cases]

The clinical manife stations and CT scans of 14 cases of intracerebral tuberculomas were reviewed. 9 cases were associated with tuberculous meningitis. The images of the tuberculomas on CT scans appeared to be disc-like, ring-like or irregular in shape. The irregular mass consisted of multiple discs or rings coalescing to produce such irregular contours. On the plain scans, fewer of the tuberculomas showed images of low density or isodenseimages they became clear images of high density on the enhanced scans. Of the 5 cases not associated with tuberculous meningitis, 3 had epilepsies. The experience obtained in recent years indicated that the majority of tuberculomas could decrease in size or completely reabsorbed with adequate antituberculous medications. For the treatment of intracerebral tuberulomas it was recommended to use regular doses of Isoniazid, Rifampin, Ethambutol and other antituberculous drugs in combination for one to one and half years. Surgery should be performed when necessary.